STARES #1: Treatment

SITUATION:

My patient was a 28yr female who 30 weeks pregnant with her 2nd child. She self presented from the community with bilateral low back pain (LBP) with the left side greater than right and also experienced numbness and tingling into L buttock on occasions. Her symptoms were aggravated by prolonged standing at end of long day and eased with rest. No other abnormal sensations or muscle weakness were associated with her symptoms.

This patient had similar pain with previous pregnancy but at later stage which was effectively managed with physiotherapy a back brace for extra support.

There was no history of trauma or any change in activities that were related to the onset of her latest episode of LBP.

On physical examination, her LBP but not buttock symptoms was reproduced with extension and left side flexion and the symptoms in her left buttock provoked with a left unilateral PA on L5/S1. Sacro-iliac joint (SIJ) tests were negative, and the patient in fact felt relief with SIJ compression. Neurodynamic tests (SLR) were also negative.

My PPIVM assessment found increased movement on the left side L3-S1 into extension and left side flexion, but no reproduction of pain.


TASK:
My task was to treat this patient who I had performed the subjective and objective examination on who presented with what appeared to be a L5/S1 control dysfunction into the direction of extension/left side flexion.


ACTION:
My baseline assessment prior to treatment was the level of pain into extension and L side flexion.

As a treatment I then performed a grade III unilateral PA glide on L5/S1 transverse process for 30s and then reassessed.

Re-assessment of combined extension/left side flexion movement showed an increase of pain and worsening of symptoms into the buttock. Immediately I realised that I had not treated it as a control dysfunction bur as a mobility restriction and as a result made the patients symptoms worse.

Following this re-assessment my supervisor stepped in and completed the rest of the treatment session with the patient with me observing.

Her treatment consisted of lumbo-pelvic muscles stabilisation exercises, targeting the pelvic floor and transverse abdominus and gluteus medius.

The patient was also given these exercises as a home exercise program.


RESULT:
The final result for the patient was no dramatic reduction in pain following her physiotherapy session, but the pain that I flared up initially had settled. The stabilisation exercises were effective but will require the patient to continue with them independently for maximal benefit. I have booked the patient in for a follow-up treatment in one week’s time to reassess lumbo-pelvic control



EVALUATION
On reflection, I performed a sub-optimal treatment technique for this patient choosing to perform an incorrect manual therapy technique. Luckily for my patient however my supervisor intervened and the pain did ease following the stabilisation exercises.

I now realise that I should have picked up key features from the subjective & objective examinations as to whether it was a control or mobility problem in this patient. For example, pregnancy, relief with SIJ compression, increased movement on PPIVMs into direction of dysfunction all suggests control dysfunction.

Even though I knew which direction to treat into for a control dysfunction, when put on the spot I treated as mobility and am not sure why. I think because I was not 100%confident in my diagnosis and then where to go with treatment techniques, I fell back on manual therapies, which I got mixed up with. As a result of my confusion and being unsure of the optimal treatment for this patient, I treated her incorrectly and subsequently worsened her symptoms.



STRATEGIES
To improve on my performance with LBP patients, I revised key features of both control and mobility dysfunctions and LBP treatment algorithms.

I also went over our lab manuals and lecture notes in what were the best techniques for improving lumbo-pelvic muscle control, especially for pregnant patients.

In addition to these strategies, at the time of the situation I documented and then asked to go over with my supervisor the exercises she had done with the patient and the best way to progress those (as the patient improved.

I also reviewed my anatomy of the lumbar spine and handling during a PPIVM assessment as I feel that a lot of my uncertainties stemmed from not being confident in what I was feeling in regards to whether there was too much or not enough movement.

Furthermore, I have asked my supervisor to, when possible, feel a variety of lumbar spine patients (especially PPIVMs) to be able to appreciate the difference between normal’s and increased or decreased movement.